Download Appendix B

Revised 01/13/13
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Confined Space Hazard Assessment & Entry Permit
Confined Space to be Entered:
Reason for Entry:
___________
Date of Entry: ____________
Authorized Entrants:
Start Time: ____________
____________________
Expiration Time: __________
Authorized Attendants:
____________________
____________________
____________________
Check Known Hazards:
Hazardous Atmosphere
Oxygen Deficiency
Slip
Toxic
Flammable
Dust
Lighting
Fire
Fall into Opening
Unexpected Energization
Burns
Heat Stress
Electrical Shock
Chemical Irritation
Engulfment
Entrapment
Other - Please List:
List Additional Hazards Created By Task To Be Completed, e.g. welding fumes, oxygen depletion,
toxic chemicals:
____________________________________________________________________________
____________________________________________________________________________
Additional Permits Needed: ___________________________________________________________
____________________________________________________________________________
Measures Taken Eliminating All Confined Space Hazards:
Equipment Locked Out - Please List:
____________________________________________
Line Breaking – Please List:
____________________________________________
Atmosphere Naturally Ventilated - Note: To be completed when Hazardous Atmosphere is checked
under Known Hazards or when any welding, chemicals, or
anything else which might affect the atmosphere is introduced
into the confined space.
Forced Air or Exhaust Ventilation Required
Low Voltage Lighting - Note: Used with any wet conditions.
Additional Lighting
Warning Signs
Caution Tape
Revised 01/13/13
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Fire Extinguisher
Ladders
Two Way Communication Radios
Safety Harness & Retrieval Line - Note: Not required when the retrieval system would not contribute to the rescue of the entrant.
Mechanical Winch - Note: Mandatory when vertical drop of 5 or more feet exist in confined space.
Personnel Informed of Potential Hazards
Other PPE Required For Task Performed - Please List:
Rescue Procedures (describe):
_______________________________________________________________________________________________________________________
Communication Procedures (describe):
_______________________________________________________________________________________________________________________
Atmospheric Testing: To be completed when Hazardous Atmosphere for Oxygen, Flammability or Toxicity is checked under Known Hazards or
when any welding, chemicals or anything else which might affect the atmosphere is introduced into the confined space.
Allowable Limits
Record Monitoring Results Every Hour
NA
Oxygen
19.5% - 23.5%
(initial reading)
______
______
______ ______
Flammability (LEL/LFL)
Under 10%
(initial reading)
______
______
______
______
Carbon Monoxide
Under 35 PPM
(initial reading)
______
______
______
______
Toxics
< TLV OR PEL
(initial reading)
______
______
______
______
Testers: ____________________________, ____________________________
Special Instructions:
___________________________________________________________________________________
___________________________________________________________________________________
I certify that I have reviewed the work authorized and understand all requirements for entry into the above listed confined space. All requirements, including
notifying the entry rescue team, have been fulfilled for safe confined space entry in accordance with the Confined Space Entry Program.
Entry Supervisor Signature: ______________________________________________________
Relieving Entry Supervisor Signature: ______________________________________________
Unusual events during entry: NONE or YES ___________________________________________________________________
CANCELLATION OF ENTRY PERMIT
Entry operation has been completed. This entry permit is cancelled. All entrants have exited the space and
have been notified of the cancellation. The space can be safely returned to normal operation.
Supervisor:
Date:
Annual Review done by:
Date:
Time:
Return Completed Confined Space Entry Permit Forms to Safety Coordinator